How is it possible that a baby who appears to have tethered oral tissues can seem to be breastfeeding fine and then suddenly begin experiencing problems? Why do some babies with obvious oral restrictions have normal breastfeeding outcomes in the early days? Why are the breastfeeding problems associated with tethered oral tissues so diverse and present in such a wide range of symptoms?

I believe the answer lies in the basics of milk flow (more here), which is something which has been relatively well-understood by lactation professionals for a long time. Milk flow is a highly variable factor in breastfeeding. In a dyad with no breastfeeding issues, milk flow is rarely considered or discussed. Among non-IBCLCs who provide routine, basic breastfeeding management education and support, it is commonly observed that in most situations where a baby gulps milk or detaches early in a feeding to allow a fast flow of milk to spray out, rarely does a mother need anything but a washcloth and a word of encouragement to move past this typically infrequent occurrence. Those same breastfeeding support providers also know that if this problem persists or creates additional symptoms or outcomes, the dyad requires further evaluation by an IBCLC.

In cases where breastfeeding problems are present, milk flow becomes a tremendously critical value to consider. A thorough understanding of the timeline for progression of milk flow over days as well as within a feeding and throughout a day lends important information to understanding what is happening when the baby is feeding at the breast. Considering variations in flow provides a broader comprehension of the infant's capacity for normal function and expectations for improvement. For example, an infant dealing with a fast flow of milk from an engorged breast on day 4 may exhibit symptoms of breastfeeding difficulty, but knowing how milk flow is expected to change over the following days and with more frequent and thorough breast emptying provides important context in supporting and educating the mother.

Flow is a tricky factor when it comes to breastfeeding problems because you can't see it! You can only see how the baby reacts to it while he breastfeeds. If a baby is breastfeeding through a nipple shield, the shield can mask the problem or even bypass it, delaying appropriate evaluation of breastfeeding, which is an excellent reason that only a qualified lactation professional who intends to follow the dyad closely should consider recommending the use of a nipple shield. If you are working with a breastfeeding mother and baby and you suspect the baby is struggling to manage the flow of milk, refer to an IBCLC. Likewise, if other breastfeeding problems present and you are unable to assist the mother by providing basic breastfeeding management education and techniques, refer for professional care by an IBCLC. Complex breastfeeding situations demand excellent and thorough clinical lactation care by a board-certified professional.